Population Health Care Manager- QuEST

Job description

Duke Connected Care , a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and itssurrounding areas. Population Health Care Manager (PHCM) – QuEST Position Summary The Population Health Care Manager (PHCM) is responsible for providing clinical expertise to manage the healthcare needs of designated patient populations across the continuum of care. The primary objective of this role is to improve patient health outcomes, enhance access to care and community resources, reduce unnecessary healthcare utilization, and lower overall costs. As an integral member of an interdisciplinary care team, the PHCM coordinates patient-centered care through seamless transitions, access management, and ongoing support. This role focuses on chronic disease management, preventive care, hospital follow-up, care coordination, and addressing medical, behavioral health, psychosocial, and social determinants of health needs across a variety of settings, including clinics, community locations, and patient homes. Under the direction of the QuEST Manager, the PHCM also supports organizational quality initiatives through education, staff development, performance improvement, regulatory compliance, and clinical quality management activities. Core Responsibilities Care Management and Coordination Manage a designated caseload and coordinate assessments, care plans, interventions, and follow-up activities for assigned patient populations. Conduct comprehensive evaluations of patient health status, social determinants of health, behavioral health needs, substance use concerns, economic factors, trauma history, and environmental influences. Develop and implement individualized, patient-centered care plans designed to address identified barriers and health concerns. Support chronic disease management and disease prevention initiatives. Coordinate transitional care management activities, including discharge planning and placement into the most appropriate level of care (e.g., skilled nursing facilities, assisted living, home health services, caregiver-supported home settings). Perform medication reconciliation and provide medication education and adherence support. Facilitate preventive care and quality gap closure initiatives. Connect patients with primary care providers, specialists, behavioral health services, social services, and community resources. Patient and Family Engagement Engage patients, caregivers, and support systems in care planning and decision-making processes. Utilize a whole-person approach that addresses medical, psychosocial, behavioral, spiritual, and social needs. Assess patient understanding, readiness for change, and ability to maintain health behavior modifications. Apply evidence-based teaching and learning principles to promote self-management and patient empowerment. Educate patients and families regarding chronic illnesses, treatment plans, and the physical and emotional impacts of health conditions. Interdisciplinary Collaboration Collaborate with physicians, primary care providers, nurses, specialists, psychiatrists, social workers, discharge planners, and community partners to ensure coordinated care delivery. Facilitate communication among interdisciplinary team members to reduce fragmented care and optimize clinical outcomes. Coordinate transitions of care across healthcare settings and community-based services. Develop and maintain positive working relationships with internal and external stakeholders. Outreach and Community Engagement Provide in-person, telephonic, and virtual outreach to patients, providers, and community partners. Conduct visits in patient homes, clinics, community organizations, and other approved settings when clinically appropriate. Ensure services are culturally responsive and sensitive to diverse patient populations. Identify and address barriers to care through community resource engagement and partnership development. Documentation and Quality Monitoring Maintain accurate, timely, and complete documentation of all care management activities within Maestro and other designated systems. Monitor patient outcomes and intervention effectiveness using measurable short-term and long-term goals. Participate in quality assurance, performance improvement, and population health initiatives. Analyze data from medical records, claims, reports, and performance metrics to identify opportunities for intervention and improvement. QuEST Program Responsibilities Education and Staff Development Design, develop, and implement educational programs for care management staff and stakeholders. Support onboarding, orientation, and ongoing professional development initiatives. Promote adherence to evidence-based practices and organizational standards. Training Facilitation Complete and facilitate organizationally designated training programs, including: Mental Health First Aid Motivational Interviewing Community Resiliency Additional approved training programs supporting quality improvement, education, and workforce development Curriculum Development Develop educational materials and learning modules based on identified organizational and programmatic needs. Utilize evidence-based content and innovative instructional strategies to address skill gaps and performance opportunities. Policy and Procedure Development Assist in the development, review, and maintenance of Population Health Management Organization (PHMO) policies and procedures. Ensure alignment with industry best practices, regulatory requirements, and organizational goals. Regulatory Compliance Ensure compliance with applicable federal, state, accreditation, and organizational requirements. Maintain adherence to healthcare quality standards and documentation expectations. Clinical Quality Management Apply clinical expertise to assess, implement, and evaluate initiatives that enhance quality outcomes and operational efficiency. Lead performance improvement projects designed to improve care management effectiveness and patient outcomes. Auditing and Performance Improvement Conduct audits and analyze quality and performance data. Identify trends, gaps, and opportunities for improvement. Develop and implement corrective action plans, educational interventions, and workflow enhancements. Stakeholder Satisfaction Promote high levels of customer and stakeholder satisfaction by ensuring responsive, patient-centered service delivery. Incorporate stakeholder feedback into continuous quality improvement efforts. Additional Responsibilities Provide recommendations to leadership regarding payer negotiations, care management improvements, and opportunities to address gaps in care. Perform other related duties as assigned. Minimum Qualifications Education Bachelor of Science in Nursing (BSN), or Master’s degree in Counseling, Social Work, Psychology, Behavioral Health, or a related field that supports licensure through an approved North Carolina licensing board. Experience Minimum of three (3) years of relevant clinical experience. Licensure and Certification For Nursing Candidates Current Registered Nurse (RN) license in North Carolina or a compact state license. For Behavioral Health Candidates Current North Carolina licensure in one of the following: Licensed Clinical Social Worker (LCSW) Licensed Clinical Addiction Specialist (LCAS) Licensed Clinical Mental Health Counselor (LCMHC) Certification Requirement Case Management Certification (ACM, CCM, or ANCC) required within three (3) years of hire. Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values. Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.